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Course: Mental Health Nursing

Topic: Therapeutic Nurse-Client Relationship - Part I

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Module Goals

Learners will be able to:

Define the therapeutic relationship, including its purpose and phases.
Explain the phases of therapeutic nurse-client relationship.
Compare barriers & facilitators of verbal & non-verbal communication.

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Therapeutic Relationship

Kornhaber, 2016

Refers to the close, consistent association that exists between at least two individuals in therapy.
Encompasses caring, and supportive nonjudgmental behavior.
Embedded in a safe environment even in stressful periods.
Can last for a brief time or continue for extended periods.
Displays warmth, friendliness, genuine interest, empathy, and the wish to facilitate and support.

Image by: Wikimedia

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Importance of Therapeutic Nurse-Client Relationship

Kornhaber, 2016

Opens the line of communication.
Fosters mutuality, trust and collaboration.
Facilitates effective communication.
Provides a supportive environment enhances clinician–client engagement and communication.
Increases adherence to treatment, setting goals, plans and promotes positive clinical outcomes.
Increases client satisfaction.

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Importance of Therapeutic Nurse-Client Relationship

Kornhaber, 2016

Allows for real-time feedback concerning client’s care and therefore allow coaching opportunities.
Improves client’s perception of quality care activities.
Responds to client’s emotional and unmet needs.
Facilitates a reduction in feelings of isolation, loss of control, and distress.

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Components of Therapeutic Nurse-Client Relationship

Trust: Essential component; once breached difficult to re-establish.
Respect: Recognize individual’s uniqueness, dignity, regardless any other status.
Professional Intimacy: Intimate care like bathing creates professional closeness.
Empathy: Understanding and validation and confirmation.
Power: Ensure the power is not misused.

College of Nurses of Ontario, 2020

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To make sure the client’s needs are prioritized, nurses must understand that the following five components are always present in a therapeutic nurse-client relationship:

Trust: Trust is critical to the therapeutic relationship. It may be fragile at first, and nurse need to make continual effort to maintain it.
Respect: A nurse has to recognize an individual’s uniqueness, dignity, worth regardless of socioeconomic status, personal attributes, and the nature of their health problem
Professional Intimacy: Providing intimate care like bathing creates professional closeness. Professional intimacy can also involve being privy to psychological, spiritual, and social elements identified in clients’ care plans.
Empathy: A nurse has to understand, validate, and confirm what the health care experience means to the client. Nurses must ensure that they maintain appropriate emotional distance from the client to ensure objectivity and appropriate professional response.
Power: Ensure the power is not misused. For example, the nurse has more authority and influence in the healthcare system (confidentiality, advocacy), and that power has to be used appropriately without misusing power or violating rights, boundaries misusing any rights.

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Therapeutic Relationship: Pre-Interaction Phase

College of Licensed Practical Nurses of Newfoundland and Labrador, 2017

Initial phase
The only phase in which the client does not directly participate.
Nurse actions:

Gather relevant information before meeting the client.
Anticipate client concerns prior to the first interaction.
Become aware of potential client concerns before meeting with the client.

Image by: Wannapik

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Therapeutic Relationship: Orientation Phase

College of Licensed Practical Nurses of Newfoundland and Labrador, 2017

Define the purpose, roles, and rules of the process, and provides a framework for assessing client’s needs.
Build a sense of trust by providing the client with basic information.
Begin to trust and know each other as partners in the relationship.
Apply the basic principles of building a relationship i.e. trust, respect, honesty and effective communication.

Image by: Wannapik

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Orientation Phase

Defines the purpose, roles, and rules of the process and provides a framework for assessing client’s needs
The nurse begins to build a sense of trust by providing the client with basic information.

Name, professional status, and essential information about the purpose and nature of the relationship).
Introductions are important even when the client is confused, aphasic, unresponsive, or unable to respond.
Nonverbal supportive communication such as a handshake, eye contact, a smile, and appropriate body language reinforce spoken words.
Respect the client’s dignity, orient oneself, environment, emergencies, call bells, end and the start of the shifts, and how the shift would generally look.

The client and nurse begin to learn to trust and know each other as partners in the relationship.
A nurse is aware of the basic principles of building a relationship, i.e., trust, respect, honesty, and effective communication.

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Therapeutic Relationship: Working Phase

The problem-solving phase of the relationship.
Parallels the planning and implementation phases of the nursing process.
Nurse helps client disclose their concerns/issues.
Plan is implemented based on the problem identified.
Thorough assessment.
Possibility of new problems.
Advocate for and empower client to represent their perspective and priorities.

College of Licensed Practical Nurses of Newfoundland and Labrador, 2017

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Working Phase

The problem-solving phase of the relationship paralleling the planning and implementation phases of the nursing process.
Clients can more deeply disclose concerns/issues that they are having, and the nurse will assist the client in exploring thoughts and feelings.
Problems issues are identified, and plans are implemented accordingly.
The nurse continues performing thorough assessment throughout.
New problems may arise.
The nurse empowers the clients and advocates for the client to represent the perspective and priorities of the client.
Focuses on self-direction and self-management to whatever extent possible in promoting the client’s health and well-being.

Providing information and teaching to a client with anger management, the importance of pursuing healthy lifestyles, red flags
Self-disclosure: Sometimes, during the working phase of the relationship, the nurse may choose to self-disclose information about themselves to relate to the client. Limited self-disclosure may be beneficial when it helps the client express their feelings as they relate their experience to what the nurse has disclosed.

Strategies to keep self-disclosure at a therapeutic level:

Self-disclosure used to help clients open up to the nurse and not for nurse’s personal needs
Disclosure should be kept brief, and should not imply that nurse’s experience is the same as that of the client

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Therapeutic Relationship: Termination Phase

Final stage

Occurs when no more care from the healthcare provider is needed i.e after recovery.
Response to treatment is evaluated.
Discuss met goals.
Ends with mutual understanding and celebration of goals.
Both parties may experience growth.
Validating plans for the future may be a useful strategy.
Increased autonomy of both parties is observed in this phase.

College of Licensed Practical Nurses of Newfoundland and Labrador, 2017

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Case Study

A nurse is establishing acceptance, trust, and boundaries with a client who is a victim of domestic violence.

Which phase of the therapeutic relationship is this?

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Standard Statements

College of Nurses of Ontario, 2006

There are four standard statements, each with accompanying indicators, which describe a nurse’s accountabilities in the nurse-client relationship.

Effective Therapeutic Communication
Client-Centred Care
Maintaining Boundaries
Protecting Clients from abuse

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Standard Statement:

Effective Therapeutic Communication

Communication is the form of exchanging and expressing information, feelings, ideas, views between person-person that can result in understanding (Cambridge Dictionary, n.d.)

Effective Communication: More than just exchanging information; It’s about understanding the emotion and intentions behind the information (Helpguide, 2020)

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Standard Statement: Therapeutic Communication

Therapeutic Communication: An invaluable approach to interactions with clients across multiple disciplines that focuses on client’s safety, comfort, trusts, emotional, social, physical and mental wellbeing (Sharma & Gupta, 2021)

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Importance of Effective Communication

Tiwary et al, 2019

Ernstmeyer & Christman, 2021

Poor communication may result in negative outcomes:

Decreased adherence to treatment
Client dissatisfaction
Inefficient use of resources

Common types of professional communication include reports to health care team members, handoff reports, and transfer reports.

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Types of Communication

Verbal communication:

An exchange of information using words understood by the receiver in a clear, concise a way that conveys professional caring and respect

Non-Verbal Communication:

80% of communication is nonverbal
Includes body language, facial expressions, tone of voice, pace
Identifying the non verbal cues is a key to provide professional caring
SOLER

Ernstmeyer & Christman, 2021

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Case Study

A client is feeling vulnerable and scared. Examples of strategies that the nurse may use to promote a therapeutic relationship include which of the following?

Introduce themselves and explain their role in the hospital
Explain what to expect during hospitalization
Allow time to ask questions
Ask about concerns and priorities of care
Listen attentively and demonstrate empathy
Involve client in planning of care

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While being aware of verbal and nonverbal messages and communicating assertively, it is also important to be aware of others’ personal space

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Common Barriers to Effective Communication

Jargon: Using complex language, medical terminology.
Lack of attention: Busy schedule/workload leads to of lack of attention.
Distractions and Noises: Noise from TVs, people talking can interfere with communication.
Light: Too much or lack of light may interfere with communication.
Hearing or speech problems: Deafness and blindness.
Cognitive disorder

Ernstmeyer & Christman, 2021

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Common Barriers to Communication in Health Care

Jargon: Medical terminologies complicated words are not understood by clients without a medical or nursing background.
Lack of attention: A client will never communicate appropriately with a healthcare member if they do not feel valued and the healthcare provider does not pay the client full attention.
Noise and other distractions: Health care environments can be very noisy with people talking in the room or hallway, the TV blaring, alarms beeping, and pages occurring overhead. These factors can easily distract the client and make them irritated/tired not to communicate.
Light: A room that is too dark or light can create communication barriers.
Hearing and speech problems: If clients have hearing or speech impairment, they cannot understand and express themselves.
Cognitive disordeer may affect understanding

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Common Barriers to Effective Communication

Language differences
Cultural differences
Physiological barriers
Differences in perception and views
Physical barriers for nonverbal communication.

Ernstmeyer & Christman, 2021

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Common Barriers to Communication in Health Care

Language differences: If a client speaks a different language and does not understand the language spoken by the care provider, then it creates a breach in the communication chain.
Differences in cultural beliefs: The norms of social interaction vary greatly in different cultures and the ways that emotions are expressed. For example, the concept of personal space varies among cultures, and some clients are stoic about pain, whereas others are more verbally expressive.
Psychological barriers: Psychological states of the sender and the receiver affect how the message is sent, received, and perceived. For example, if nurses are feeling stressed and overwhelmed with required tasks, the nonverbal communication associated with their messages such as lack of eye contact, a hurried pace, or a short tone can affect how the client perceives the message. If a client is feeling stressed, they may not be able to “hear” the message or they may perceive it differently than it was intended. It is important to be aware of signs of the stress response in ourselves and our clients and implement appropriate strategies to manage the stress response. See the box below for more information about strategies to manage the stress response.
Physiological barriers: If a client is in a lot of pain or discomfort, it is less likely that the client will hear, concentrate and remember what the care provider said or explained.
Physical barriers for nonverbal communication: Virtual checkups, email, and text messages are less effective than face-to-face communication. The inability to view the nonverbal communication associated with a message, such as tone of voice, facial expressions, and general body language, often causes misinterpretation of the message by the receiver.
Differences in perception and viewpoints: Everyone has their own beliefs and perspectives and wants to feel “heard.” When clients feel their beliefs or perspectives are not valued, they often become disengaged from the conversation or care plan.

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Overcoming Barriers:

Ernstmeyer & Christman, 2021

Jargon: Use simple language, avoid medical terminology.
Lack of attention: Focus on the client, give them full attention.
Noise and other distractions: Create a calm, quiet environment, close doors, reduce the TV volume, or move to a quieter area.

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Critical Thinking Question

Imagine you have a client who speaks a different language and does not understand your language. An interpreter is not available in your facility.

How would you communicate your plan for the day to the client?

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Overcoming Barriers:

Ernstmeyer & Christman, 2021

Light: Ensure the lighting as per client’s preference.
Hearing and speech problems: Enhance the communication by the use of sign language, interpreter, tactile sign language.
Language differences: Medical interpreter, written handouts in the client’s preferred language.
Differences in cultural beliefs: Respect the culture, listen, do not judge, have intercultural awareness and use culturally appropriate body language, language.

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Overcoming Barriers

Physiological barriers: Address and treat the cause of physiological barrier. eg. pain.
Physical barriers for nonverbal communication: When possible, use face-to-face communication so that nonverbal communication is included with the message.
Differences in perception and viewpoints: Provide health care information in a nonjudgmental manner, even if the client’s perspectives, viewpoints, and beliefs are different from one’s own.

Note: For more information about effective therapeutic communication please click here

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Physiological barriers: Address and treat the cause of the physiological obstacles. E.g., pain. If a client is in pain, they are less likely to hear and remember what was said, so pain relief should be provided as needed before delivering client education.

However, it is also important to remember that sedatives and certain types of pain medications often impair the client’s ability to receive and perceive messages, so a client cannot sign health care documents after receiving these types of medications.

Physical barriers for nonverbal communication: When possible, it is best to deliver important information to others using face-to-face communication to include nonverbal communication with the message.

Providing information via e-mail or text is often less effective than face-to-face communication. The inability to view the nonverbal communication associated with a message, such as tone of voice, facial expressions, and general body language, often causes misinterpretation of the message by the receiver.

Differences in perception and viewpoints: Everyone has their own beliefs and perspectives and wants to feel “heard.” When clients feel their beliefs or perspectives are not valued, they often become disengaged from the conversation or care plan.

Nurses should provide health care information nonjudgmentally, even if the client’s perspectives, viewpoints, and beliefs are different from their own.

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Red Flags

Safety.
Always consider safety when interacting with clients who may have an emotional disorder..
Do not try to initiate a conversation if the client is angry and acting out.
Always have a plan for an exit in any communication encounter.

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Cultural Considerations

Cultural considerations may impact the appropriateness of personal space when providing client care.

Example: In the Chinese culture,

It is considered impolite to talk disagree or say No.
May not talk openly about their problems.
Assume their problem can be easily understood by the health professionals.

Queensland Health, n.d

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Cultural Considerations

In Philippines:

Doctors and nurses are generally highly respected for their knowledge, education and expertise and few Filipinos will question them.

In indian culture:

Indian clients may say yes in order to please the health professional, even if they do not understand the concept or treatment.
Expect that a physician, not the nurse, will gather a complete history and perform a thorough examination.

Queensland Health, n.d

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References:

Cambridge Dictionary. (n.d). English: Communication definition. https://dictionary.cambridge.org/dictionary/english/communication

College of Licensed Practical Nurses of Newfoundland and Labrador-CLPNNL. (2017). Therapeutic Nurse-Client Relationship Interpretive Document. https://www.clpnnl.ca/sites/default/files/2017-04/Therapeutic_Nurse-Client_Relationship_Interpretive_Document_2017.pdf

College of Nurses of Ontario. (2006). Standard of Care: Therapeutic Nurse-Client Relationship. https://www.cno.org/globalassets/docs/prac/41033_therapeutic.pdf

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References:

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0.

Helpguide. (2020). Effective Communication. https://www.helpguide.org/articles/relationships-communication/effective-communication.htm#:~:text=Effective%20communication%20is%20about%20more,and%20intentions%20behind%20the%20information.&text=Effective%20communication%20sounds%20like%20it,with%20others%20something%20goes%20astray.

Kornhaber, R., Walsh, K., Duff, J., & Walker, K. (2016). Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review. Journal of multidisciplinary healthcare, 9, 537–546. https://doi.org/10.2147/JMDH.S116957

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References:

Queensland Health. (n.d). Multicultural Clinical Support Resource: Cultural Dimension of Pregnancy, Birth and postnatal care. https://www.health.qld.gov.au/__data/assets/pdf_file/0035/158669/14mcsr-pregnancy.pdf

Sharma N, Gupta V. (2021, May 11). Therapeutic Communication. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK567775/

Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor communication by health care professionals may lead to life-threatening complications: examples from two case reports. Wellcome open research, 4, 7. https://doi.org/10.12688/wellcomeopenres.15042.1

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